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Postoperative management of laparoscopically assisted vaginal hysterectomy (09HDC00816)

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(09HDC00816, 15 September 2009)

Gynaecologist ~ Private hospital ~ Laparoscopically assisted vaginal hysterectomy (LAVH) ~ Delayed recovery ~ Perforated ureter ~ Preoperative information ~ Information about scar ~ Postoperative information ~ Open disclosure ~ Rights 4(1), 6(1)

A 54-year-old woman underwent a laparoscopic hysterectomy performed by a gynaecologist at a private hospital. The surgery was complicated owing to adhesions from three previous Caesarean sections. On the second postoperative day the woman still had not passed flatus, had nausea and vomited. The gynaecologist suspected a mild paralytic ileus, and treated her conservatively but did not investigate whether in fact she did have an ileus. The woman was discharged six days after her original surgery, having passed flatus and a bowel motion. The gynaecologist did not see the woman before authorising her discharge by telephone.

Four days later the woman's condition deteriorated and the gynaecologist admitted her to a public hospital, where she was found to have pneumonia, pleural effusion, and a bowel obstruction from a perforation which had occurred during the LAVH. This required removal of the affected colon and formation of a de-functioning colostomy. The woman appeared to recover well initially but suffered a setback when she was diagnosed with a urinary tract infection. A CT scan revealed a distended left ureter, and a CT urogram found the ureter leaking at the junction of the bladder. The injury was thought to have occurred during the LAVH. The woman was transferred to a second public hospital for insertion of a nephrostomy tube and stent. 

It was held that the gynaecologist should have recognised that the woman's recovery was not following the expected pattern. In failing to adequately investigate the delay in recovery, the gynaecologist breached Right 4(1). The gynaecologist was held to have provided an appropriate standard of surgical care, and adequate preoperative and postoperative information. It was noted that a patient would reasonably expect to be told about the likelihood and nature of a scar, in the event of the need for open surgery.

It was also held that the private hospital provided appropriate care and information to the woman, and did not breach the Code.

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